Program Forms

Interim Change Application

Please complete this form anytime you have a change in income, benefits, employment, etc. Once completed, return this form to our office at 916 South 14th Street along with any paystubs, bank statements, benefit letters, and any other income information. Please be advised that an Interim Change can take up to 60 days to process since we will need to verify all the household income.

Zero Income Worksheet

This worksheet is to be completed by anyone in the household, 18 or older, who currently has no income. This form usually goes with the Interim Change Application, especially if there is a loss of employment or benefits. Please be sure to complete the form correctly, by reading each line item. Keep in mind that there should be no zeros in for the dollar amount, if you use or have that particular line item. If the items come from a food bank, church or family member, it still must have a dollar value.

Request to Move

If you are thinking about moving out of your current unit, this form will start the process. Simply complete the form and submit it to your case manager and an appointment will be set up for you to receive the required paperwork to move. For additional information see this form: Relocating to Harrisburg